As the incidence of measles in 2019 increases, the likelihood of health care providers, including dermatologists, seeing patients with this highly infectious disease will also increase. As of May 24, 2019, the Centers for Disease Control and Prevention (CDC) reported 940 cases of confirmed measles in 26 states in the United States (US)—an increase of 60 cases from the week before.1 This is the largest measles outbreak in the US since 1994 and has resulted in a mandatory vaccination requirement and fines against unvaccinated individuals in Brooklyn, New York, as well as a quarantine of two universities in Los Angeles, California.2,3
Other parts of the world are experiencing major outbreaks as well, with over 34,000 cases confirmed in Europe (predominantly in Ukraine) by the World Health Organization on May 7, 2019.4 Chad is expected to experience one of the worst outbreaks due to low vaccination rates.5 Other countries impacted by the outbreak include Israel, Philippines, Japan, and Brazil, for which the CDC has issued travel warnings.6,7 Visit the CDC for a full list of areas impacted by measles (https://www.cdc.gov/measles/travelers.html).
Due to the success of vaccinations, which led to the declaration by the CDC that measles was eradicated in the US in 2000, many dermatologists and health care providers likely have not seen or treated patients with this disease. Steven Tyring, MD, PhD, with the department of dermatology at McGovern Medical School in Houston, TX, spoke with The Dermatologist about the recent epidemic, symptoms of measles, and what dermatologists need to know in order to effectively reduce the impact of this outbreak among patients, especially those who are more susceptible to infectious diseases.
Rise of the Vaccine and Antivaccination Movement
Prior to the measles vaccine, which was first made available in 1963, approximately 549,000 cases and 495 measles-related deaths were reported per year in the US.6 Unreported cases were estimated to be about 4 million among US children. Of the reported cases, 48,000 patients were hospitalized, and 1000 patients developed chronic disabilities from acute encephalitis associated with measles.6 Recommendations for two vaccines, one at 12 months and one between 4 to 6 years, were issued following a large outbreak in 1989.
Despite the efficacy of vaccines for preventing highly infectious diseases, the circulation of antivaccine sentiments has led to decreases in vaccination below the needed threshold for herd immunity. According to Dr Tyring, there are two reasons people are not vaccinating. “One is people who are having children now have not had measles or know of anyone who has had measles,” he said. “They do not realize the disease is still around because in 2000, the CDC considered it eliminated from the US. However, it was not eliminated from the world and when people travel to areas without the vaccine, they can potentially bring it back into the US.”
The second reason, according to Dr Tyring, “is the unfounded fear of vaccinations.” Since the publication of Andrew Wakefield’s paper that fabricated a “link” between vaccines and autism and other adverse events,8 an antivaccination movement has spread throughout the US, United Kingdom, and parts of Europe. While the paper has been widely discredited and a multitude of findings show no connection between autism and vaccines, the dissemination of false information from Wakefield’s paper and other misinformation through social media continues to fuel antivaccination sentiments and vaccine hesitancy among parents.
Antivaccine sentiments, in combination with laws allowing religious exemptions for certain communities in the US, has led to reduced vaccination rates and created an environment where measles can easily spread. Parents wanting to do what they believe is best for their children are often vulnerable to misinformation and can be swayed by narratives and fears propagated by antivaccine groups. Providers in all disciplines should be aware of ways to encourage vaccination compliance among patients and caregivers. These resources can help providers discuss misinformation and create dialogue with caregivers and patients who are hesitant to complete the required vaccinations (Table 1).
Who Is at Risk?
Measles is a highly infectious disease that predominantly affects children. However, both children and adults who have only received one dose of the vaccine are at increased risk of measles. Adults born between 1963 and 1989, when the second dose of the measles, mumps, and rubella (MMR) vaccine was first recommended, may only have had one shot. Likewise, adolescents and young adults whose parents were not compliant with both doses could have only received a single dose. These patients will need a booster to improve their immunity to measles, as a single dose of MMR does not ensure the 97% protection against the virus that is provided with two doses6 (Table 2).
Additionally, providers should be vigilant as more patients who would have “aged out” of the traditional age group for measles may present with symptoms, particularly in outbreak areas, because the first few generations of children born to parents with antivaccine sentiments are now becoming young adults.
Patients who are immunocompromised are more likely to experience the worst outcomes and die from measles. These could be patients with cancer, HIV/AIDS, and those who are receiving an immunosuppressive medication or underwent an organ transplant. Malnourishment is another immunocompromising state that is associated with worse disease outcomes, particularly in less developed countries were famine is high and access to vaccines is low.
“Thousands of people around the world die from measles because they are malnourished and do not get a chance to receive the vaccine. As a result, they often get measles pneumonia, and/or secondary bacterial infections, and die from it,” said Dr Tyring.
Additionally, Dr Tyring added, newly born infants are at risk because the vaccine is not administered until 12 months of age. “They have about a 6-month window where they might be partially susceptible to the virus,” he explained. Infants and those who are unable to receive the vaccine rely on herd immunity to avoid measles.